The Culinary Revolution Has Come for Hospitals

When a cycling accident put Margherita Stewart Sagan in the hospital a few years ago, the food was inedible. Her plate of chicken, she said, “looked like it had been washed in the fast cycle of the laundry machine.”

Sagan wasn’t expecting a gourmet meal, but she was surprised how little hospital cuisine had changed since her previous overnight stay. Decades earlier, during her C-section recovery, the food was just as awful. “I basically starved,” she told me.

Her two experiences, more than 20 years apart, inspired her to open the restaurant Noon All Day, strategically located near two San Francisco hospitals. Since last year, Sagan and her partner, Sher Rogat, have been serving healthy food designed to travel well. It’s aimed at patients and their loved ones, as well as all the healthcare providers and hospital employees who’ve been choking down laundry-machine chicken. Offerings include salads with avocado and apple, chia puddings and Moroccan-spiced chickpea pancakes.

“We’ve made a pact with each other,” said Rogat. “If anything, god forbid, should happen, I will always bring her food because we all know now that the food at hospitals is not up to our standard.”

Meals served on hospital trays have historically amounted to unappetizing, nutritionally empty fuel. As culinary traditions go, this one doesn’t make a lot of sense: The benefits of a diet rich in plant-based foods and low in processed ones are supported by a vast body of scientific research. According to a recent study published in JAMA, almost half of deaths due to heart disease, stroke or type 2 diabetes are associated with poor diet. Yet at institutions devoted to fighting disease and improving health, candy and white bread are often easier to find than fresh fruits and vegetables.

A few hospitals, however, are starting to invest in healthier, tastier cuisine, forgoing flash-frozen dinners for local ingredients and hiring chefs to create the types of food that patients and hospital employees might look forward to eating — and visitors might even stick around for.

Scopes

Nutritional blind spot

Most hospitals and healthcare facilities in the U.S. have contracts with behemoth industrial food corporations like Aramark, which also provides food service to prisons. Many hospitals also have on-site fast-food restaurants, like McDonald’s and Chick-fil-A, although some are letting these contracts expire in response to mounting pressure from groups like the nonprofit Physicians Committee for Responsible Medicine, which recently ranked the most hazardous hospital environments in the country.

“Without pointing fingers, this is the way it’s always been,” said Dr. David Eisenberg, director of culinary nutrition at the Harvard T. H. Chan School of Public Health. “People, after cardiac surgery, shouldn’t be getting Hoodsies and mystery meat. It’s preposterous. We don’t hand out cigarettes to people on the pulmonary ward. Why are we feeding them garbage after they have cardiac or gastrointestinal problems? It’s ridiculous. But because this is the way it’s always been, I think it will continue being that way, until people stand up and say, ‘That’s scandalous!’”

“There are a lot of great hospitals with great MRI machines and great surgeons, but there are very, very few that serve good food.”

This nutritional blind spot may be partially due to how physicians are trained in the first place. “Nutrition has never been front and center as part of the job of a doctor,” Eisenberg said. “To this day, doctors are not tested on their certification exams on their ability to advise patients on which foods they should eat more of or less of.”

For now, the task falls to a number of pioneers working to make changes at the grassroots level. Eisenberg, who happens to be the son and grandson of professional bakers, reached out to the Culinary Institute of America 20 years ago, proposing they collaborate with Harvard on a conference where health professionals could talk about advising patients on eating and cooking wholesome, nutritious foods. Two years ago, he helped launch the Teaching Kitchen Collaborative, a hub for organizations that have built on-site “teaching kitchens,” which are like laboratories for nutritional health. Of the TKC’s 41 members, 13 are healthcare organizations, including giants like Kaiser Permanente and Cleveland Clinic.

“How do you incentivize people to build teaching kitchens?” Eisenberg asked. “Well, right now we can’t.”

But he’s playing the long game. “The bigger issue is,” he said, “can we imagine hospitals becoming showcases of excellent food that teach people to cook it and communities to grow it?”

An executive chef touch

It might be hard to envision hospitals ascenters of culinary innovation, but a growing number of chefs are trying to make that happen.

Chef Bruno Tison, who grew up and trained in France, at first seems like an incongruous presence in a hospital kitchen. Last year, Northwell Health, New York state’s largest healthcare system and a member of the Teaching Kitchen Collaborative, hired him as their vice president of food services and corporate executive chef.

At first, Tison was hesitant to say yes — after all, his resume includes time at the Plaza Hotel and a few Michelin stars. But then he saw the healthcare industry as a new frontier for the culinary arts.

“Let’s be honest with each other,” he told me. “The healthcare industry has neglected food and nutrition. There are a lot of great hospitals with great MRI machines and great surgeons, but there are very, very few that serve good food.”

He was impressed that Northwell wanted to serve healthy, locally sourced meals with an executive chef touch. But there are challenges, Tison says: “The equipment is antique, sometimes 20, 30 years old. We can no longer find the parts to repair it. In healthcare, we think about buying a new MRI machine before a stove.”

Tison’s job entails training new chefs at Northwell’s 23 hospitals and revamping menus. It also requires advocating for larger cultural reform. “You have to change the culture, because in a hospital a lot of people do not believe food is important,” he said. “They believe that people come to a hospital to be treated and that’s all. But it’s much, much deeper than that.”

In addition, some Northwell hospitals now have what they call a “food pharmacy,” where they offer free, wholesome food, left over from vendors, to low-income patients. They also teach food-prep and nutrition classes.

In addition to changing hospitals’ food culture, Tison has found ways to save money, negotiating new deals with local vendors. “We were buying processed, packaged bread from I-won’t-tell-you-who,” he laughed. “And we have renegotiated a contract with three Manhattan artisanal bakeries, the same the finest restaurants in New York City are using. We’re going to be serving artisanal breads to our patients as well as our employees. And we saved $100,000.”

Other changes include a move from premade liquid coffee to the fresh-ground variety, and from frozen precooked chicken to fresh, antibiotic-free — all while saving Northwell hundreds of thousands of dollars.

Farm to operating table

Austin Buhler, the executive chef at Central Valley Medical Center in Utah, has been doing something similar on a smaller scale since the hospital hired him to improve the quality of patient meals. Before he came on, the hospital — a 25-bed acute-care facility — offered only “heat and serve” industrial fare. Now Buhler is bringing in fresh clams to make clam chowder, and local acorn squash that he stuffs with wild rice and cranberries.

“Our lettuce comes from a farm 20 minutes from here,” he said. “Our tomatoes and produce come from another farm.” He makes a point to share this information with patients when he visits them, which he does regularly. Sometimes a patient will know the farmer personally, he’s found: “It brings them into it.”

In addition to designing the room-service menu patients order from, Buhler oversees the cafeteria where employees and families eat. “I started getting to know the patients, the hospital staff, the doctors, and I fell in love with it,” he said. “I love being the one person that walks into the hospital room that lights up their faces. I’m not there to prod them, I’m there to bring them their food.”

Chefs I spoke with pointed out that better food also encourages families to stick around and eat on site, a welcome revenue boost for the hospital.

The hospital clientele is an added bonus. Serving royalty and 1,000-guest celebrity weddings, Tison explained, “you very, very rarely get a thank you.” At hospitals, people are grateful.

Healthcare is a new world for him: “When I see the eyes of a patient who received a beautifully prepared meal, something special for a patient who has had a hard time recovering, you should see people with tears in their eyes, being so thankful. The first time that happened, I had to turn around, because I was starting to cry myself.”

“It just takes courage to do it,” Eisenberg said, of changing the way hospitals serve food. “These are the kinds of things the Teaching Kitchen Collaborative, this small band of crazy thought leaders, are attempting to demonstrate. If the medical community and the culinary community partner, we might have a way forward. And if we don’t, shame on us.”

Cole Kazdin is a writer and Emmy-winning television journalist living in Los Angeles. She is a regular contributor to Vice, has written for the New York Times and Refinery29 and has been featured on NPR as part of the Moth Radio Hour.

Dig Deeper

In response to your article, quotes from Austin Buhler, I applaud the skills you have brought to CVMC but part of what you have stated is not totally true, which offends me. I was the Certified Food Service Manager from 2011-2015, and revamped the department which included to have 95% of the food prepared and served was made from scratch and I improved and revamped the menus and the patient satisfaction scores improved 56 %. I may not be a trained chef but I have a degree in culinary management , and 25 years of experience in health care food services and a Certified Dietary Manager since 1993 which is required to manage a food service department in most hospitals and health care facilities. I also am a member of Association of Nutrition & Foodservice Professionals and have proudly served as President of ANFP Utah.

Read this next

For people with irritable bowel syndrome, it’s common to hear that symptoms such as cramping, alternating diarrhea and constipation, and bloating are “all in their head.” In the case of IBS, there’s actually some truth to this.

It’s not that their symptoms don’t exist. IBS is a very real disorder, and managing its physical toll often becomes an all-consuming effort. The litany of concerns that accompany so many activities — always scouting the closest bathroom, making sure you can reach it in time, farting in public — keeps many people with IBS from having a social life.

Yet according to some experts, IBS is not solely about what’s going on in the digestive system; rather, the brain exacerbates the condition. “IBS is a disorder of brain-gut dysregulation,” explains GI psychologist Sarah Kinsinger, who is also co-chair of the psychogastroenterology section of the Rome Foundation. Accordingly, addressing the “brain” side of IBS through cognitive behavioral therapy with a trained psychologist may help decrease both the anxiety that’s often associated with the disorder and its physical symptoms.

“CBT really should be the first-line treatment for people with IBS. It’s the treatment with by far the most empirical support, and when done well, it can be curative,” says Melissa Hunt, associate director of clinical training in the psychology department at the University of Pennsylvania.

In a series of trialspublished last year, researchers in the UK compared the standard treatment for IBS (typically diet and lifestyle modifications and/or medication) with eight sessions of CBT delivered over the phone or online. Before and after the trials, participants answered questionnaires designed to measure their anxiety, depression and ability to cope with their illness. Two years after the trials, 71 percent of the phone-CBT group and 63 percent of the online-CBT group reported clinically significant changes in their IBS symptoms. Meanwhile, less than half of the standard-treatment group reported such an improvement. Those who did CBT also exhibited lower levels of anxiety and depression and higher coping ability than other participants.

In an earlier meta-analysis (a study of studies), published in 2018 in the Journal of Gastrointestinal and Liver Diseases, a different team of researchers also found that CBT appeared to reduce both psychosocial distress and the severity of IBS symptoms, with a greater effect on the physical symptoms than on the mental ones.

Explainers

The brain-gut connection

How this happens is not completely clear at this point, but it’s believed to have something to do with how the gut and brain communicate.

“IBS is thought to be a disorder of centralized pain processing,” Hunt explains. “There is miscommunication between the pain centers in the brain and the nerves in the gut. In people with IBS, pain signaling gets inappropriately amplified.” Discomfort that wouldn’t even register in the majority of people feels like being stabbed in the gut to a person with IBS. “The best way to address that is to find ways to help reduce pain signaling, and that’s with a psychologist,” Hunt says.

CBT for IBS entails learning relaxation techniques, such as diaphragmatic breathing and progressive muscle relaxation, which help reduce the “volume” of the pain signals by activating the parasympathetic nervous system, i.e., the body’s “rest and digest” response. “This can also lead to increased blood flow and oxygen to the digestive system, which helps the GI tract to function in a more rhythmic way,” says Kinsinger, who is also an associate professor at Chicago’s Loyola University Medical Center.

CBT also involves thought restructuring. IBS can cause a cycle of worry: Worrying about symptoms leads to being hyperfocused on the slightest hint of any symptom, which increases anxiety, which aggravates symptoms. People with IBS also often catastrophize, meaning they assume the worst will happen (“If I have an accident at work, I’ll get fired and never get another job”), develop social anxiety and become withdrawn. CBT addresses these issues by shifting attention away from IBS symptoms and using exposure therapy to help people gradually engage in more activities outside their homes.

Additionally, using CBT, people with IBS learn to identify and change dysfunctional ways of thinking. For example, consider someone with school-aged children who asks their spouse to attend all school functions because they’re afraid of farting in a room with other parents, which would inevitably cause humiliation and might even make people think they’re disgusting A therapist might ask them how often they notice bodily noises from other people to help them realize that we’re a lot more cognizant of our own bodily functions than other people are. “In other words, we identify the catastrophic beliefs and then search for evidence supporting them or not,” Hunt says.

CBT is a skills-based, goal-oriented approach to treating mental disorders that emerged in the mid-20th century. All CBT programs share the same underlying goal of helping patients identify and modify negative or unhelpful thought patterns and behaviors. “It teaches patients techniques that they can then implement on their own.” says Kinsinger. “It can be done pretty efficiently, depending how motivated and receptive one is to learning these skills.” But over time, customized versions of CBT have been developed for specific conditions including insomnia, schizophrenia and IBS. Different versions of CBT use different techniques, such as role-playing, exposure therapy and relaxation exercises, and vary in length. On average, CBT for IBS lasts between 4 and 10 sessions in total.

Jeffrey Lackner, professor and chief of the division of behavioral medicine at the University at Buffalo, SUNY, says their program is structured like a course: “You learn a specific skill to manage your GI symptoms, process information differently or respond to stress in a less extreme way. Then you practice that skill in session before using it in the real world.” Often therapists also give patients homework to fine-tune the skills they learn. They come out of CBT with a toolbox of techniques to manage the day-to-day burden of IBS.

Some people with IBS do CBT on their own, using self-help books, online materials or apps without ever seeing a therapist. “Not many psychologists are trained to treat GI disorders specifically, so physicians don’t often have anyone to refer patients to,” Kinsinger says. The Rome Foundation trains psychologists and maintains a directory of gastrointestinal psychologists, but if someone can’t find a provider in their area, Hunt and Kinsinger recommend looking for a psychologist who’s trained in CBT and has experience treating chronic pain, panic disorders or anxiety.

Reducing sensations vs. reducing sensitivity

Not everyone is fully on board with CBT for IBS. One 2018 review study found “insufficient evidence to demonstrate the effectiveness of online CBT to manage mental and physical outcomes in gastrointestinal diseases” including IBS. A different 2018 review concluded that although psychological treatments for IBS appear to help in clinical trials, it’s unclear if they work in other settings and which treatments — such as CBT, mindfulness-based stress reduction and guided affective imagery — are most effective.

IBS is a complex problem, and some doctors prefer to integrate CBT with other treatments. But “by the time we see them,” Lackner says, “many of our patients have found that the medical treatments have not provided adequate symptom relief.”

Some IBS patients also find thetraditional approaches too hard to stick with. The most commonly prescribed treatment is a “low-FODMAP” diet, which requires giving up all dairy and legumes, plus many grains, fruits and vegetables. “Some trials show that even if the diet reduces or eliminates GI symptoms, it doesn’t improve quality of life because it’s crazy restrictive,” Lackner points out.

“With IBS, the nerve endings in the gut have become hypersensitized, and the brain magnifies those signals in the gut,” Hunt says. “The low-FODMAP diet tries to reduce the sensations, whereas CBT reduces the hypersensitivity. When you turn down the volume on the sensations, then you can eat whatever you want.”

Whether CBT helps with this brain-gut dysregulation, addresses distorted thinking and anxiety, or increases confidence in a person’s ability to manage gastrointestinal symptoms — or all of the above — it’s helped people with IBS resume parts of their life they’d put on hold.

Brittany Risher is a writer, editor and digital strategist specializing in health and lifestyle content. She's written for publications including Men's Health, Women's Health, Self and Yoga Journal.

Dig Deeper

About us

The Paper Gown, powered by Zocdoc, covers health and healthcare with a focus on patient experiences — inside and outside the exam room, before check-ups and after surgery, across all states of health. We strive to tell stories that help patients feel informed, empowered and understood. Learn more.